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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address ]� f� /T I/1�t.t City s 1•• Lot Size PM Owner's Name Address ��QQ..�� Phone�]✓ �� Contractor �OAILA k Address d License No. 8 ? Phone TYPE OF WELL/PUMP: .NEW,WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl PUMP INSTALLATION EJ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DIS OSAL FLD. PROP. LINE FOUNDATION AGRICULTU WELL O ER WELL P S/SUMPS INTENDED USE TYPE OF WELL ROBLEM ARE CONSTRUCTION ECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Ex ation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casi Specifications ❑ Public ❑ Other ❑.D a 4 Depth of rout Seal Type of Grout ❑ Irrigation _..Appro . Depth ❑i astern 4y Surface eat Installed by Repair Work Done ❑ Type of P mp H.P. State Work Done Well Destruction ❑ Well Diameters' r Sealing Material (top 50') f ,. Depth `R r Filler,Material_I Below_50'�, `� TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is f #. available within 200 feet.) Installation will serve: Reen 'dce� Commercial Other Number of living units: Number of beds oms S� ixr- � ► 1 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK K Type/Mfg "� Capacity o Q' No. Compartments 1 PKG. TREATMENT PLT. ❑ l�� , �-- .- Method of ispos�l • r + Distance to nearest: Well �T Fdundation z�., 7 ,Property Line LEACHING LINE No. & Length of lines d Total length/size ,6 C/ — 60 fl FILTER-BED _ T ❑ Distance to neo st: �We ;4oundation�.,� Property Line Q SEEPAGE PITS ❑ Depth , _Size Numbers SUMPS e0 Distance to nearest: WellFoundations Property Line p DISPOSAL PONDS E2 "1 hereby certify that I have prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in'the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call f r all required inspections. Complete drawing on reverse sid . SignedX_�64 In —.Title: Dater F DEPARTMENT USE ONLY Application Accepted by Date � '�' Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 389-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' pp FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH 1324(REV. (^�� EH 1428 (� /`Y� / !/h-